CORRECTED (If checked)
PAYER’S INFORMATION
1
 Gross distribution
OMB No. 1545-0119
Distributions From
Payer’s Name
$
Pensions, Annuities,
2a
 Taxable amount
2013
Retirement or
Street address (including apt. no.)
Profit-Sharing Plans, IRAs,
$
Form 
1099-R
Insurance Contracts, etc.
City
State
ZIP code
2b
Taxable amount not
Total
Copy B
determined
distribution
 Report this
Payer’s country
3
Capital gain (included
4
Federal income tax
 income on your
 in box 2a)
 withheld
 federal tax 
$
$
return.  If this
PAYER’S federal identification
RECIPIENT’S identification 
5
Employee contributions
6
Net unrealized 
form shows
number
number
/Designated Roth                 appreciation in 
federal income
contributions or 
employer’s securities
tax withheld in
RECIPIENT’S name
insurance premiums
box 4, attach
$
$
 this copy to
Street address (including apt. no.)
7
Distribution 
IRA/ 
8
Other
 your return.
This information is
City
State            ZIP code
SIMPLE
being furnished to
$
%
the Internal
Recipient’s country
9a
Your percentage of total
9b
Total employee contributions
Revenue Service.
distribution
%
$
10
Amount allocable to IRR
11
1st year of desig. Roth contrib.
12
State tax withheld
13
State/ Payer’s state no.
14
State distribution
within 5 years
$
/
$
$
$
/
$
Account number (see instructions)
15
Local tax withheld
16
Name of locality
17
Local distribution
$
$
$
$
Form 
1099-R
Department of the Treasury - Internal Revenue Service
code(s)             SEP/ 
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